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T3 a iIC:noms FOR CCDMPLIA a FC3 `
<br /> GENERAL I S1RUC,HO Se
<br /> L One FORM"13'shall be completed for each tank for all NEW PERM.n S,ILE I'C C'ES, FMO I:a and/car any
<br /> otherTANK DC7 'ICD _CIIIANGF_
<br /> 1 This form should be completed by either the PE I'I PLIC. I'or the LOCAI.,AGENCY UNDERGROUNDTANK
<br /> INSTEC70k
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point waiting instrument,you are snaking 3 copies.
<br /> FOP'OF FORM: 'MARK ONLY ); 1I ITE M*
<br /> L ' Mark an (X) in the box Next to the item that best describes the reason the;foray is being completed.
<br /> 2. indicate the 1733,1 or I"cility rsante where the tank is installed.
<br /> I. TANK DESC;ICfE°HO =UOM°I FIE AL L rll` MS-IF UNKNOWN-SO SPIXIF
<br /> A. _Indicate owners tank I7 # -If these is a tank number that is used by the owner to identify thew tank(ex.AB70789).
<br /> B. indicate the name of the company haat manufactured the tank(ex.ACMF °I'Aty M1,G,).
<br /> C. Indicate the year the tank was installed(ex. 1987),
<br /> I7. Indicate; the tank capacity in gallons(ex,25,000 or 10,000 etc.),
<br /> H. TANK CON'llfiNIN
<br /> A. 1. If MOTOR'VFIJiCL IUE'L,check box 2 and complete iteans I3& C;,
<br /> 2, If not MOTOR V1,113CLE FUFL,check the appropriate box in section A.and complete items B& D.
<br /> B. Cheek the appropriate box.
<br /> the in ),
<br /> ID, Check
<br /> rrintthe chemicalaname of the hazardous substanVEHICLE FUEL,(if ce checkedx 1 is
<br /> stored thta l and the C;.2V5. . (Chemical Abstract Service
<br /> umber),if box 1 is NOT checked in A.
<br /> III. TANS C.ON9'IB:IJ TIO ONE17172A ONLY IN BOX A,II,C&T
<br /> 1.. Check only one item in TYPE Ofi'SYSTEM,TANK MAI'ERIAI.., IN`1'ERlOR LINING and CORROSION i'ROTEC71710N.
<br /> 2, If C7THI:Rt print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> I. Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> 2. If L;NKNIOWN,cirslc; or if OTHER,print in space provided.
<br /> 3. Indicate the I1',1I4 D 'I1; `rI0N systern(s) used to comply with the rno itormg requirement for the;piping. ,
<br /> V. TANK LEAK DVI IN II(7rd<
<br /> 1. Indicate the LIAK D13-FEC IJON systean(s) used to comply with the monitoring requirements for the tank.
<br /> INIAC) 7110TH ONTANK PERMANEW.11MC'I;CDSt iS IN PLACE
<br /> 1 ,- ESTIMATED C A'FE IASF USIH)-MONT`II/Yl'AA 2(January, 1988 car 01/88).
<br /> 2. ESTIMA`i'I I7 O 'ANTTFY of I Zt1.3 DOCS SUBSTANCE remaining in the tank (in Gallons).
<br /> 3; WAS TANK FILLED WHIT I ER71`MATERIAL? Check'Yes'or'?°O',
<br /> ArrucAmr : I'SIGN AND DA.MT'11I.E FORM AS INDICKIED,
<br /> IN LIC®5 TC) TC`I`IIE? AIC'.AI. GENCIE-S
<br /> The state underground storage tank identification number is composed of the two digit county number, the three;digit jurisdiction
<br /> number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Hoard(916)139-2421. The facility number roust be the same as shown in form"A". The
<br /> tank number may be assigned by the laical agency however,this number must be numerical and cannot contain an alphabet. if
<br /> the local agency prefers the State Board to assign the tank number,please leave it blanTc.
<br /> EI'IS TLI3 Rf.i!SP0NS II 1' "017'111E LOCAL AGENCY IN.1'IN PLa,UR "IM7 FAC ILr. ' t3 VERIFY'ITIS
<br /> ACCURACY OF Tal?it i J I € N. IE IDCAL ACN][INC "IS R SP NSI LE I'f R TILE CCI PI..ITZC) .
<br /> 'WC'AL AGENCY U%E d3NLV IWC RIa A'€7ON BOX AND FORR ARID J ONI. IrC)RM'A"AND ASSO 1KI,Ir
<br /> MRM,SIT"(s "tom'tT1I;17011,0WING ADDRIM.
<br /> S VVI7I1 OF C' ,IAC) A
<br /> CIO& .h$E.P.S
<br /> DA'I°A PROCESSING CEN1711,R
<br /> RO.13OX 527
<br /> PA . MOU ',CA`90723
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